S&C Individual_ Small Group Training Paperwork

Client Information
Training Type

IndividualSmall Group
Last Name
First Name
Todays date
Address
City/State/Zip
Mobile Phone
Home Phone
Work Phone
DOB
Email
example@example.com
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relationship
Athlete Questionnaire
What sport do you play
Position
Grade
Age
Sport Experience (yrs)
Weight Training Experience (yrs)
Injury History (if any)
Height
Weight
Athlete Goals
Please list any abilities that you would like to achieve as a result of your strength consultation and program design.

Ex: Decrease 40 yd dash time; Increase muscle size/strength, etc.,
Abilities
Performance Metrics
10yd
5-10-5 Shuttle
Vertical Jump
Broad Jump
Bench (1Rm)
Squat (1RM)
PTSP Agreement
Waiver: In consideration of the fees paid, participant understands that there is a risk of personal injury in the course of instruction and, with this knowledge, agrees to assume the risk of any injury and damages while inside the facility of Physical Therapy San Pedro. Participants further agree to strictly obey trainers and observe safety rules.

I understand that Physical Therapy San Pedro will maintain my privacy to the highest standards and may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment.

Photographs taken during the time the participant is in the facility will be used for postural comparison purposes and as educational tools. By signing below I consent to the use of these photographs in a professional manner.

, have read and understand this release and agreement and agree to its provisions. I am not under the influence of any drugs, alcohol, or other intoxicants. I am not suffering from any illness or incapacity. I am over 18 years of age. (If not over 18 years of age, a parent or guardian must sign
I (Name), have read and understand this release and agreement and agree to its provisions I am not under the influence of any drugs alcohol or other intoxicants I am not suffering from any illness or incapacity I am over 18 years of age If not over 18 years of age a parent or guardian must sign
Name
Signature

Clear
Date

MonthDayYear
Date
Parent Signature if under 18 years old

Clear
Date

MonthDayYear
Date
Should be Empty:

Client Information

Athlete Questionnaire

Athlete Goals

Performance Metrics

PTSP Agreement